Question

A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

Answer 1

Correct Answers:

Hives on the child's neck.

Rationale :

⚠️ Hives (urticaria) on the neck or any part of the body after a hepatitis B immunization can indicate an allergic reaction or anaphylaxis, which is a life-threatening emergency.

⚠️ Early signs of anaphylaxis often include hives, itching, swelling, and respiratory symptoms, and require immediate intervention (e.g., epinephrine, airway support).

⚠️ The other findings—redness at the injection site, mild fever, and prolonged crying—are common, expected reactions to vaccination and are not immediately life-threatening.

⚠️ Prompt recognition of hives allows for early treatment and prevention of progression to more severe symptoms like airway obstruction or shock.

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Answer 2

Correct Answers:

Ibuprofen.

Rationale :

🍼 Ibuprofen is not recommended for infants under 6 months of age, due to the risk of renal impairment and gastrointestinal irritation in immature kidneys and digestive systems.

🍼 The infant in this scenario is 5 months old, making acetaminophen the preferred antipyretic and analgesic for fever management.

🍼 The temperature (39.2°C), heart rate, respiratory rate, and blood pressure are all within expected or explainable ranges for a febrile infant and do not require clarification.

🍼 Therefore, the nurse should clarify the ibuprofen prescription before administration, ensuring age-appropriate medication safety.

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Answer 3

Correct Answers:

Encourage the family to involve siblings when caring for the child.

Rationale :

🌈 Involving siblings in the care of a terminally ill child fosters family cohesion, allows siblings to process the situation in a healthy way, and provides a sense of inclusion and support.

🌈 School-age children are capable of understanding the concept of death and benefit from open, age-appropriate conversations and involvement.

🌈 Avoiding the topic of death or excluding siblings can contribute to emotional distress, guilt, or confusion.

🌈 Frequent vital signs and strict passive ROM are not appropriate for end-of-life care, where comfort, dignity, and family presence are prioritized over routine clinical interventions.

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Answer 4

Correct Answers:

"It is not your fault that this happened.”.

Rationale :

🧸 The most supportive and therapeutic response the nurse can offer to a child suspected of experiencing physical maltreatment is to affirm that they are not to blame.

🧸 Children who have been abused often struggle with guilt, shame, and fear, and reassurance that they are not responsible is essential to their emotional safety and recovery.

🧸 Avoid promising confidentiality , since healthcare providers are legally required to report abuse.

🧸 Comments such as "This should not have happened" or "You should have told someone sooner" may seem sympathetic but can inadvertently place blame or pressure on the child.

🧸 The goal is to create a safe, trusting environment where the child feels believed and supported.

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Answer 5

Correct Answers:

Groin area.

Rationale :

🧷 An inguinal hernia occurs when abdominal contents, such as a portion of the intestine, protrude through the inguinal canal—a passage located in the groin area.

🧷 In infants, it typically presents as a soft, sometimes reducible bulge in the groin that may become more noticeable when the infant cries, coughs, or strains.

🧷 Palpation of the groin while the infant is calm or during crying can help detect this hernia.

🧷 The abdomen, lower back, and upper thigh are not primary areas for detecting inguinal hernias.

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Answer 6

Correct Answers:

5

Rationale :

Step 1: Convert weight from pounds to kilograms

33lb÷2.2=15kg

Step 2: Calculate total daily dose

50mg/kg/day×15kg=750mg/day

Step 3: Divide the total daily dose into 3 doses (every 8 hours)

750mg/day÷3=250mg per dose

Step 4: Use available concentration to find mL per dose

250mg /5mL=50mg/mL

250mg per dose/50mg/mL=5mL

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Answer 7

Correct Answers:

Apply an ice collar.

Rationale :

❄️ After a tonsillectomy, applying an ice collar helps reduce throat pain, swelling, and bleeding by promoting vasoconstriction.

❄️ This is a non-invasive comfort measure that is well-tolerated by preschool-aged children and can reduce the need for systemic pain medications.

❄️ Cherry juice should be avoided because its red color can mask signs of bleeding.

❄️ Coughing and deep breathing are contraindicated in this setting as they may dislodge clots and increase bleeding risk.

❄️ Straws should not be used postoperatively due to the suction pressure, which can also increase the risk of hemorrhage.

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Answer 8

Correct Answers:

Choose a helmet that is light in color and covers your ears.

Rationale :

🚴 A properly fitted bicycle helmet is essential for preventing head injuries. Helmets should be light in color for high visibility, making the rider more noticeable to drivers.

🚴 The helmet should fit snugly, sit level on the head, and cover the forehead and the sides (including above the ears) without obstructing vision or hearing.

🚴 The balls of the feet should not touch the ground while seated—rather, the rider should be able to touch the ground with their toes while straddling the frame.

🚴 Children should walk, not ride, their bicycles through crosswalks and intersections for safety.

🚴 Bicyclists should ride with the flow of traffic, not against it, to follow traffic laws and ensure predictability.

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Answer 9

Correct Answers:

Hard-boiled egg.

Rationale :

🍳 A hard-boiled egg is a nutritious, soft-textured snack that is appropriate for toddlers and poses minimal choking risk when cut into small pieces.

🍳 It provides essential protein and healthy fats to support growth and development.

🍳 Grapes, raw carrots, and popcorn are common choking hazards for toddlers and should be avoided or modified (e.g., grapes should be peeled and cut into quarters).

🍳 Safe snack choices for toddlers should be soft, easy to chew, and cut into small, manageable pieces.

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Answer 10

Correct Answers:

I should administer this medication 30 minutes before breakfast.

Rationale :

🌅 Lansoprazole is a proton pump inhibitor (PPI) that works best when given 30 minutes before a meal, typically before breakfast, to reduce gastric acid secretion.

🌅 It should be swallowed whole or the contents sprinkled on a small amount of soft food if the child cannot swallow capsules—not chewed or placed under the tongue.

🌅 The usual dosing is once daily, not four times per day, unless specifically adjusted by the provider.

🌅 Administering it before meals enhances its effectiveness by allowing it to block acid pumps before they are stimulated by food.

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QLexNursing

1 :
A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

3 :
A nurse is assisting with the care of a school-age child who is terminally ill. Which of the following interventions should the nurse perform?

4 :
A nurse is caring for a child and suspects the child has experienced physical maltreatment. Which of the following statements should the nurse make?

5 :
A nurse is collecting data from an infant. Which of the following areas should the nurse palpate to check for an inguinal hernia?

7 :
A nurse is assisting with the care of a preschooler who is immediately postoperative following a tonsillectomy. Which of the following actions should the nurse take?

8 :
A nurse is reinforcing teaching about bicycle safety with a school-age child. Which of the following instructions should the nurse include?

9 :
A nurse is reinforcing dietary teaching with the guardians of a toddler. Which of the following snack foods should the nurse recommend?

10 :
A nurse is reinforcing teaching with a parent of a child who has gastroesophageal reflux disease and a new prescription for lansoprazole capsules.
Which of the following statements by the parent indicates an understanding of the teaching?

QLexNursing

1 : A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

3 : A nurse is assisting with the care of a school-age child who is terminally ill. Which of the following interventions should the nurse perform?

4 : A nurse is caring for a child and suspects the child has experienced physical maltreatment. Which of the following statements should the nurse make?

5 : A nurse is collecting data from an infant. Which of the following areas should the nurse palpate to check for an inguinal hernia?

7 : A nurse is assisting with the care of a preschooler who is immediately postoperative following a tonsillectomy. Which of the following actions should the nurse take?

8 : A nurse is reinforcing teaching about bicycle safety with a school-age child. Which of the following instructions should the nurse include?

9 : A nurse is reinforcing dietary teaching with the guardians of a toddler. Which of the following snack foods should the nurse recommend?

10 : A nurse is reinforcing teaching with a parent of a child who has gastroesophageal reflux disease and a new prescription for lansoprazole capsules. Which of the following statements by the parent indicates an understanding of the teaching?

1 :
A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

3 :
A nurse is assisting with the care of a school-age child who is terminally ill. Which of the following interventions should the nurse perform?

4 :
A nurse is caring for a child and suspects the child has experienced physical maltreatment. Which of the following statements should the nurse make?

5 :
A nurse is collecting data from an infant. Which of the following areas should the nurse palpate to check for an inguinal hernia?

7 :
A nurse is assisting with the care of a preschooler who is immediately postoperative following a tonsillectomy. Which of the following actions should the nurse take?

8 :
A nurse is reinforcing teaching about bicycle safety with a school-age child. Which of the following instructions should the nurse include?

9 :
A nurse is reinforcing dietary teaching with the guardians of a toddler. Which of the following snack foods should the nurse recommend?

10 :
A nurse is reinforcing teaching with a parent of a child who has gastroesophageal reflux disease and a new prescription for lansoprazole capsules.
Which of the following statements by the parent indicates an understanding of the teaching?